BACKGROUND/RATIONALE:
Management of patients with co-morbid hypertension (HTN) and diabetes (DM) is a costly and clinically challenging task within the VA health system. The general objective of the proposed research is to assess patient and provider attitudes toward care and to examine the degree to which similarity of attitudes held by VA patients being treated for comorbid hypertension and diabetes and by their primary medical care providers, is a determinant of patient satisfaction, patient regimen adherence, and adequacy of diabetic and blood pressure control.


OBJECTIVE(S):
Four interrelated study objectives will be addressed.

Aim 1: The proposed research will determine the relationship between patient-provider attitudinal symmetry and patient satisfaction.
Aim 2: The proposed research will determine the relationship between patient-provider attitudinal symmetry and patient medication adherence (determined using pharmacy records) and more general self-reported treatment adherence.
Aim 3. The proposed research will determine the relationship between patient-provider attitudinal symmetry and clinical measures of blood pressure (as reflected in clinic blood pressure readings) and glycemic control (as reflected in HbA1c values).
Aim 4. If (as predicted) a significant effect for attitudinal symmetry on clinical outcomes is found, the proposed research will reexamine the effects of attitudinal symmetry after adjusting for patient self-reported adherence and satisfaction. This will allow for a determination of the extent to which the effect of attitudinal symmetry on BP or HbA1c is accounted for (mediated by) differences in patient self-reported adherence and/or satisfaction.

METHODS:
The primary methods of the proposed research is to assess patient and provider attitudes toward care and to examine the degree to which similarity of attitudes held by VA patients being treated for co-morbid diabetes and hypertension and by their primary medical care providers is a determinant of patient satisfaction, patient adherence, and adequacy of blood pressure and diabetic control. This observational study will test the effects of attitudinal symmetry over an 18 month period. The study will be conducted at 2 VA medical centers (VAMCs) and their affiliated community-based outpatient clinics (CBOCs) in VISNs 23 and 12. The study will enroll approximately 55 primary-care provider participants and 660 linked, randomly selected primary care patients with previous diagnoses of co-morbid diabetes and hypertension who are being followed by a participating provider.

Psychometric measures known to reflect stable, enduring patient attitudes toward health care, as well as patient adherence and satisfaction data, will be collected at enrollment via interviews. Similarly, attitudinal and background data will be obtained at enrollment from PCPs via self-administered surveys. Additional measures of medication adherence and quality of care will be obtained from an 18 month retrospective review of patients' electronic medical records and review of VA pharmacy data.

We believe a cross-sectional / retrospective study design will allow us to address the proposed research questions in a more efficient cost-effective than the prospective longitudinal design that was proposed in our initial application. As discussed in more detail below (and as noted by the reviewers in the critique of our initial proposal), this study design will allow us to take maximal advantage of the available outcome and medication adherence data for the established provider - -patient dyads under study.

Studying patients with co-morbid DM and HTN will also enable us to examine more clinical endpoints than could be evaluated in a study focused on only one of the conditions, further increasing study efficiency.

FINDINGS/RESULTS:
Analysis has begun and continues (8/12/10).

IMPACT:
The proposed objectives represent a critical step toward understanding how patient and provider attitudes toward care might be explicitly assessed and incorporated into the evidence-based health care delivery process to enhance outcomes among veterans. At least two possibilities for future evidence-based implementation exist and will be informed by the proposed work. First, by understanding the importance of patient-provider similarity on a given dimension or background characteristic, health services researchers can then begin to examine the feasibility of matching patients to a particular medical care provider based on degree of symmetry on this dimension. Second, identifying brief assessment instruments that can validly and reliably assess patient role preferences, would allow providers as well as health care systems the opportunity to tailor the health care delivery approach to best suit a particular patient's orientation (e.g., through enhanced engagement of select patients in the treatment decision making and self-management processes).

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External Links for this Project

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PUBLICATIONS:

Journal Articles

1. Howren MB, Christensen AJ, Karnell LH, Funk GF. Health-related quality of life in head and neck cancer survivors: impact of pretreatment depressive symptoms. Health psychology : official journal of the Division of Health Psychology, American Psychological Association. 2010 Jan 1; 29(1):65-71. [view]
2. Cvengros JA, Christensen AJ, Hillis SL, Rosenthal GE. Patient and physician attitudes in the health care context: attitudinal symmetry predicts patient satisfaction and adherence. Annals of behavioral medicine : a publication of the Society of Behavioral Medicine. 2007 Jun 1; 33(3):262-8. [view]
3. Christensen AJ, Howren MB, Hillis SL, Kaboli P, Carter BL, Cvengros JA, Wallston KA, Rosenthal GE. Patient and physician beliefs about control over health: association of symmetrical beliefs with medication regimen adherence. Journal of general internal medicine. 2010 May 1; 25(5):397-402. [view]
4. Cvengros JA, Christensen AJ, Cunningham C, Hillis SL, Kaboli PJ. Patient preference for and reports of provider behavior: impact of symmetry on patient outcomes. Health psychology : official journal of the Division of Health Psychology, American Psychological Association. 2009 Nov 1; 28(6):660-7. [view]
5. Baldwin AS, Cvengros JA, Christensen AJ, Ishani A, Kaboli PJ. Preferences for a patient-centered role orientation: association with patient-information-seeking behavior and clinical markers of health. Annals of behavioral medicine : a publication of the Society of Behavioral Medicine. 2008 Feb 1; 35(1):80-6. [view]

Journal Other

1. Baldwin AS, Vander Weg MW, Christensen AJ, Rothman AJ. Examining the Causal Mechanisms Underlying Self-generated Arguments for Health Behavior Change. [Abstract]. Annals of behavioral medicine : a publication of the Society of Behavioral Medicine. 2009 Apr 1; 37(S):229. [view]

Book Chapters

1. Baldwin AS, Kellerman QD, Christensen AJ. Coping with Chronic Illness. In: Handbook of Health Psychology and Behavioral Medicine. New York, NY: Guilford Press; 2010. Chapter 33. 494-508 p. [view]

Conference Presentations

1. Kaboli PJ. Anti-Coagulation Interest Group Update. Paper presented at: Society of General Internal Medicine Annual Meeting; 2008 Apr 11; Pittsburgh, PA. [view]
2. Egts S, Baldwin A, Ishani A, Wilson HS, Vander Weg MW, Christensen AJ, Kaboli PJ. Does Patient Role-orientation Predict Patient-initiated Discussions with Providers? Insights from the VA Project to Implement Diuretics (VAPID). Paper presented at: Society of General Internal Medicine Annual Meeting; 2008 Apr 11; Pittsburgh, PA. [view]
3. Howren MB, Christensen AJ, Hillis SL, Walston KA. Patient and Physician Beliefs about Control over Health: Symmetrical Beliefs Predict Medication Regimen Adherence. Paper presented at: Society of Behavioral Medicine Annual Meeting and Scientific Sessions; 2010 Apr 10; Seattle, WA. [view]

DRA: Health Systems Science
DRE: none
Keywords: Communication -- doctor-patient, Patient preferences, Satisfaction (patient)
MeSH Terms: none